The moral malaises of modern pediatric medicine
Thèse
Franco Carnevale
Doctorat en philosophie, de l’Université Laval
offert en extension à l’Université de Sherbrooke
Philosophiae Doctor
(Ph.D.
)Faculté des lettres et sciences humaines
Université de Sherbrooke
Sherbrooke, Canada
Faculté de philosophie
Université Laval
Québec, Canada
© Franco Carnevale, 2013
iii Résumé
Le cadre éthique dominant en médecine pédiatrique est intrinsèquement problématique, car des considérations morales importantes y restent dissimulées. Ce problème correspond bien au déplacement des malaises moraux dans la modernité énoncés par Charles Taylor. En nous référant à Taylor, nous soutenons que la médecine pédiatrique contemporaine et la bioéthique reflètent la théorie morale moderne centrée sur des procédures décisionnelles, sans considération explicite des fondements moraux de telles procédures. L'objectif de cette thèse est d'examiner les préoccupations morales de la médecine pédiatrique contemporaine grâce au cadre philosophique développé par Taylor. Le travail de Taylor a orienté cette recherche (a) méthodologiquement, car sa conception de l'herméneutique a servi de cadre d'analyse ; et (b) substantivement, car son analyse de la modernité et de la théorie morale a été une référence indispensable. La philosophie herméneutique de Taylor ainsi que son analyse de la modernité sont examinés afin de retracer les horizons de signification et les imaginaires sociaux dans lesquels la médecine pédiatrique est née et s‟est attachée à des orientations morales particulières. Cette approche montre que la médecine pédiatrique apparaît 1) d‟abord lorsque les intérêts économiques et militaires de l'Etat le conduisent à valoriser la santé des enfants, 2) ensuite lorsque apparaît une orientation éthique mettant l‟accent sur l'enfant lui-même selon le critère du meilleur intérêt de l‟enfant. Trois malaises moraux ont été identifiés dans la médecine pédiatrique moderne: (a) la convergence du droit et de l'éthique; (b) la conception des enfants comme étant incapables et dépendants ; et (c) la nature ambiguë du concept du meilleur intérêt. Nous examinons ces malaises afin de révéler les horizons de signification et les imaginaires sociaux qui leur ont donné naissance. Un cadre taylorien est également proposé afin d‟enrichir la pratique bioéthique
iv
pédiatrique actuelle – la récupération et le rapprochement herméneutiques – permettant ainsi l‟accordage interprétatif et la réconciliation des considérations morales dissimulées dans le cadre éthique courant. Les implications à l‟égard de la recherche ainsi que la pratique et la formation en pédiatrie sont présentées.
v Abstract
The dominant ethical framework in pediatric medicine is inherently problematic because important moral considerations are concealed. This problem is congruent with the displacement of moral malaises in modernity articulated by Charles Taylor. Drawing on Taylor‟s work, I argue that contemporary pediatric medicine and bioethics are reflective of modern moral theory, which is centered on decisional procedures without explicit regard for the substantive moral grounds that such procedures should relate to. The goal of this thesis is to examine moral concerns in contemporary pediatric medicine through Taylor‟s philosophical work. Taylor‟s ideas oriented this examination (a) methodologically, as his conception of hermeneutics served as the analytical framework, and (b) substantively, by drawing on his analysis of modernity and moral theory. Taylor‟s hermeneutical philosophy as well as his examination of modernity are reviewed to provide a philosophical framework for tracing the horizons of significance and social imaginaries within which pediatric medicine emerged and became aligned with particular moral orientations. An operational explicitation of Taylor‟s hermeneutical approach was developed to examine (a) the early history of pediatric medicine as children‟s health became valued in light of state and
societal economic and military interests and (b) the emergence and ongoing development of the best interests standard, a more child-centered ethical orientation. Three moral malaises in modern pediatric medicine were identified: (a) the convergence of law and ethics; (b) the construal of children as incapable and dependent; and (c) the ambiguous nature of best interests. These malaises were examined to the retrieve the background horizons of
significance and social imaginaries against which they were shaped. Moreover, a Taylorian framework for the practice of pediatric bioethics is proposed - hermeneutical retrieval and
vi
rapprochement - to enrich pediatric practice through interpretive attunement and
reconciliation of concealed moral considerations. The implications for future research as well as pediatric practice and education are outlined.
vii Acknowledgements
This thesis marks the culmination of an extraordinary exploration. Although this exploration started long before my entry into this doctoral program, completing all of the requirements of this program (i.e., coursework, thesis, and numerous other related
activities) has enabled me to conduct an investigation that engaged me in so many aspects of my life. Consequently, the number of people that I need to thank is huge, as I have been discussing this work with anyone willing to humor me for many, many years. Needless to say, I cannot list all of the people that have inspired and supported this work.
First, I am deeply grateful toward the many critically ill children, their families, and the many clinicians involved in their care that I had the privilege of learning from during more than thirty years of children‟s hospital service.
I wish to thank the large network of colleagues, experts, and mentors (many of whom are listed in chapter 2) that have generously guided and enriched my thinking throughout this enormous undertaking.
Thank you to Marissa Carnevale (who was completing her studies in law while I was conducting this investigation; she is also my daughter!) as well as Gina Freeman (a masters bioethics student) for their work with me as research assistants on various research projects, which was tremendously helpful for the analyses presented in chapters 3 and 4.
I wish to thank professors André Lacroix and Alain Létourneau, at Université de Sherbrooke, for their thorough critiques during my retrospective and prospective
examinations in this program (i.e., these correspond with what is commonly referred to as „comprehensive examinations‟ in many universities). They helped strengthen my thinking and my writing.
viii
I am grateful toward Professor Jocelyn Maclure, at Université de Laval, for his “Rapport de prélecture” (i.e., thesis pre-review). His comments were thorough and highly instructive. He helped me improve the thesis and orient me toward important questions to consider for my future work in this domain.
Thank you to my family and my friends – especially my mother and late father, my late brother Michael, my daughter Marissa, and my wife Mary Ellen. They have sustained me intellectually and emotionally; and tolerated all of the time, attention, and my everyday DEEP preoccupation (frequently bordering on obsession!!) that this work has required of me.
I cannot find words to express my tremendous gratitude toward my supervisor Professor André Duhamel. He has been a true mentor throughout this lengthy process. He has guided me, coached me, instructed me, inspired me – he has helped me profoundly. He continually identified areas in which my work could be strengthened and helped me find ways to improve it. He is a truly gifted mentor. Professor Duhamel continually pushed me to do better; patiently and thoroughly reviewing my numerous drafts - always conveying his critiques with a tone of encouragement. While he helped me learn to become a philosopher, I also learned how to become a better mentor for my own students. Cher Professeur Duhamel : Je vous remercie infiniment pour votre excellente direction et votre soutien extraordinaire! Thank you, thank you, THANK YOU!!!
This work would not have been possible without the intellectual giant that inspired this project in the first place: Charles Taylor. From my initial point of contact with Taylor‟s work – over twenty-five years ago - through to the more recent immersion permitted by this thesis, I have had the wonderful experience of shifting into a new worldview – a “Taylorian philosophical anthropology”. This has transformed my entire understanding of the human
ix sciences – for the better. In addition to benefitting from his voluminous body of
publications, I am especially grateful toward the many opportunities that I have had to speak with Professor Taylor personally to discuss my questions about various facets of his work. Particularly “impactful”, was my opportunity to work with him directly on a theme issue of the Journal of Medicine and Philosophy. I am PROFOUNDLY grateful: Professor Taylor has been tremendously patient and generous toward me!!! Thank you so much!!!
Table of Contents
Résumé ... iii
Abstract ... v
Acknowledgements ... vii
Abbreviations ... xv
Frequently Cited Taylor Publications ... xv
Introduction ... 1
The Child’s best Interests and Respect for Parental Authority ... 2
Returning to Kandice ... 4
Questioning the Dominant Ethical Framework in Pediatric Medicine ... 5
Why the Philosophy of Charles Taylor? ... 10
Plan for the Thesis ... 12
Chapter 1: Hermeneutics and the Philosophy of Charles Taylor ... 15
Introduction ... 15
Section I ... 16
Shifting Perspectives in the Human Sciences ... 16
Understanding, Interpretation and Hermeneutical Philosophy ... 19
Gadamer‟s Hermeneutic Philosophy: Truth and Method ... 24
Section II ... 29
Understanding Taylor’s Human Sciences ... 29
Taylor’s Moral Framework ... 33
Interpretation and the Sciences of Man ... 37
Understanding Moral Life in Light of Social Imaginaries ... 43
The emergence of modern moral orders. ... 44
Social Imaginaries defined. ... 46
The Great Disembedding. ... 47
Three forms of social self-understanding. ... 47
The economy. ... 48
The public sphere. ... 48
A self-governing people... 48
Contemporary Social Imaginaries. ... 49
General comments on Social Imaginaries. ... 50
Section III ... 51
xii
The Emergence of Modern Individualism - Sources of the Inward Self ... 57
The Affirmation of Ordinary Life ... 61
A Final Remark on Taylor’s Modern Self ... 62
Chapter 2: Designing a “Taylorian” Examination of the Moral Malaises of Modern Pediatric Medicine ... 65
Analytical Sources ... 66
Analytical Plan ... 68
Analytical Guide ... 72
Guiding questions. ... 73
Text identification questions. ... 73
Text analysis questions. ... 73
Provisional Sources ... 74
Consultations with Scholarly Experts ... 77
Description of Analytical Chapters that Follow ... 78
Chapter 3: Early History of Pediatric Medicine ... 79
Introduction ... 79
The “Origin” of Childhood... 81
Childhood as a State Interest ... 82
Discovery of Infant Mortality... 83
Medicalization of Birth and Child Care ... 84
The Birth of Pediatrics ... 86
Legal and Policy Milestones ... 89
Provisional Hermeneutical Interpretation ... 90
Chapter 4: The Best Interests of the Child ... 97
Introduction ... 97
Legal Recognition of the Best Interests of the Child ... 97
The Tender Years Doctrine. ... 99
Children‟s best interests. ... 100
United Nations Convention on the Rights of the Child... 101
Recognition of Child’s Best Interests in Formal Ethical Norms ... 104
Clinical care of children. ... 105
Research with children. ... 106
Summary comments. ... 108
Preliminary Hermeneutical Analysis ... 109
The convergence of legal and ethical norms. ... 112
xiii
The ambiguous nature of best interests. ... 121
Concluding Remark ... 125
Chapter 5: The Moral Malaises of Modern Pediatric Medicine ... 127
Introduction ... 127
Understanding Modernity ... 128
Convergence of Law and Ethics ... 132
Child as Incapable and Dependent... 141
“Human beings” and “human becomings”. ... 142
The Ambiguous Nature of Best Interests... 149
The Dominant Social Imaginary of Modern Pediatric Medicine: Summary Statement ... 156
Political Atomism in Modern Pediatric Medicine ... 157
Concluding Remark ... 164
Chapter 6: Hermeneutical Retrieval and Rapprochement ... 167
Background ... 167
Hermeneutical Retrieval ... 168
Guiding questions for “local” hermeneutical analysis. ... 171
Source identification questions. ... 171
Analytical questions. ... 172
A proposal for an “interpretive starting point”. ... 174
Hermeneutical Rapprochement ... 179
Normative Development in Pediatric Bioethics ... 184
Conclusion ... 187
xv Abbreviations
HCP: Health care professionals SI: Social Imaginaries
Frequently Cited Taylor Publications (See references for complete details) Taylor, 1985c: Interpretation and the sciences of man.
Taylor, 1989: Sources of the self: The making of the modern identity. Taylor, 1991: The Malaise of Modernity.
Taylor, 1992a: Multiculturalism and the politics of recognition. Taylor, 2004: Modern Social Imaginaries.
1 Introduction1
Hospital to pull plug: Mother „living through hell‟ as baby to be taken off her life-support system (Gazette, 1994)2
A Toronto woman says she‟s “living through hell” after being told that the Hospital for Sick Children will discontinue ventilator life support for her baby daughter, who‟s in a deep coma.
Doctors informed Tami Knowles they‟ll disconnect the life-support system Feb. 3 because baby Kandice‟s degenerative brain disease leaves her no hope of survival.
Knowles, 27, said she‟s opposed to the decision but has been given no say in the matter.
“I just don‟t feel that I, or especially that hospital, should say your daughter is going to die on this date,” she said.
“Where are my rights?”
Kandice, born in September, was an alert, happy infant the first three months of her life, said her mother.
But the family noticed around the beginning of December that her eyes wouldn‟t focus and she would stare at the wall, “like she was in a trance.”
She was diagnosed at Toronto‟s Hospital for Sick Children with a fatal degenerative brain disease.
It‟s a “defect in the function of the mitochondria – or an inborn error of metabolism” said the hospital spokesman Claudia Anderson.
Opinions from other world renowned hospitals confirmed the diagnosis, Anderson said.
A critical-care physician at the Sick Children‟s hospital wrote to Knowles this month trying to explain the situation.
“Continuing ventilator support is not in Kandice‟s best interests,” Dr. Desmond Bohn said in his letter.
“We would ask you to understand that this is a medical decision, which is inevitable given the irreversible nature of your child‟s disease and would ask you to understand why the ventilator support cannot be continued indefinitely.” Bohn said the ventilator was supposed to be stopped last Friday but the date was
pushed back two weeks when Knowles protested. He said the baby might not even live until Feb. 3.
Knowles has complained about what she considered to be insensitive handling of the case by doctors at Sick Children‟s.
“It‟s just disgusting,” she said. “It‟s like they have no care, no compassion, anything.”
1 The American Psychological Association reference citation system is used in this thesis because it permits
(a) embedded citations of authors, for the convenience of the reader, as well as (b) footnotes to permit required elaborations. This citation system is recognized in several philosophy programs.
2 This case is used as an illustrative exemplar for the thesis. It reflects a number of common ethical concerns
identified in pediatric medicine, which are demonstrated in subsequent chapters through published empirical research. Also, as a media case in the public domain, no permission was required to discuss it for this thesis.
2
“He (Bohn) walked in like Mr. Joe Cool and said, „Your daughter is going to die on Friday.”
Pediatrician John Watts, a McMaster University specialist in medical ethics, said such decisions are becoming much more common”.
“It‟s the start of a slippery slope,” Watts said. “I find it a worrisome trend.” That‟s because there‟s less money and fewer resources, Watts said, and hospitals
want to put those dollars in a place where they will do some good.
He said he is not familiar with the specifics of Kandice‟s case, and there may be no alternative.
The Child’s best Interests and Respect for Parental Authority
Kandice‟s case is heart-wrenching. It evokes significant compassion toward the difficult circumstances of her life as well as for her family. One can also come to
understand the difficult perspectives of the clinicians involved in her care. Although this newspaper report presents a fairly unflattering view of the physician, it is highly plausible that a genuine wish to “do the right thing” was underlying his actions.
Kandice‟s case is not unlike many cases considered to be ethically problematic in pediatric medicine. It explicitly evokes well documented questions: (1) Which child‟s life should be sustained with medical technologies? (2) How should such decisions be made? (3) Who should make these decisions?
The American Academy of Pediatrics Committee on Bioethics (AAP, 1994; 1995) and the Canadian Pediatric Society (CPS, 2004) have published statements on consent and decision-making with children. These indicate that, for children who cannot give consent themselves, parents should be responsible for granting permission for treatment while giving great weight to the clearly expressed views of the child when possible.
Decisions regarding children call for the use of the “best interests” standard, weighing the proportional balance of the benefits and burdens related to the various treatment options. These recommendations are consistent with the prevailing bioethical
3 and legal norms regarding the care of children in North America.3 These norms are legally recognized in all North American jurisdictions. Although there may be instances where physicians may act in a paternalistic manner, this is generally denounced through hospital complaints procedures, legal proceedings, or through the public media.4
Under usual circumstances, parental authority is so well recognized in North America that in cases where physicians disagree with parental wishes, they need to obtain court authorization to provide refused medical care (AAP, 1994; 1995; CPS, 2004).5 This quasi-absolute parental authority for their children‟s care is rooted in a broader Anglo-Saxon norm of respect for personal and family autonomy. It is generally held that it is not for the state to decide how families should raise or care for their children, except for cases of suspected child abuse or neglect.6
3The emergence of these norms is examined in detail in the best interests analysis that follows in chapter 4. They can be traced largely to the Report on Studies of the Ethical and Legal Problems in Medicine and
Biomedical and Behavioral Research published by the (U.S.) President's Commission for the Study of Ethical
Problems in Medicine and Biomedical and Behavioral Research (President's Commission, 1983). This Commission sought to address the rising number of ethical controversies emerging in health care practice and research. Ethical norms asserted by this report that are directly relevant for this thesis included: (1) informed consent is required from competent patients; (2) surrogate decision-making is required for incompetent patients (i.e., the surrogate should typically be a family member); (3) parents should ordinarily be the surrogate decision-makers for children who are too young to be legally permitted to consent for themselves (upholding parental and familial autonomy – except for situations where parents are considered neglectful or abusive); (4) medical decisions for incompetent patients and children should be determined according to the treatment option that serves the patient‟s best interests, through a weighing of the benefits and burdens implied by each option.
4 For example, the Canadian National Film Board released the documentary Médecine sous influence (2004)
wherein parents voiced their contestations toward physicians who saved their children‟s lives through resuscitative medical care, which, according to the parents, resulted in severe disability. These parents asserted that they would not have consented to life-sustaining measures if they had been given a choice.
5 For example, court authorization is commonly sought to administer blood products to children of Jehovah‟s
Witnesses. These situations, along with related legal considerations, are discussed later in the thesis.
6 For a comprehensive review of contemporary ethical issues in pediatrics, see Miller‟s (2010) edited book
Pediatric Bioethics. Several papers from this collection are cited throughout this thesis. Numerous other
publications address additional issues. For example, in a general discussion of pediatric bioethics, Miller (2003) has argued that pediatric medicine requires a shift in the ethical approaches that are predominantly used with adults; a shift from autonomy to beneficence. According to Miller, “beneficent medical decision-making” in pediatrics requires a “therapeutic alliance” between physicians and families and children. A significant body of literature has focused specifically on ethical concerns in neonatology. In their examination of the recent history of the medical care of newborns, Lantos & Meadow (2006) highlighted three principal eras in the United States: (1) the recognition of neonatology as a distinct medical specialty, during which time
4
Returning to Kandice
With these norms in place, the resolution of Kandice‟s case would appear fairly straightforward. The decision to provide continued mechanical ventilation or not should be based on her best interests; i.e., the treatment option that would provide the greatest benefit in relation to burden should be chosen. On the basis of the widely recognized decision-making norms outlined above, the assessment of Kandice‟s interests would ordinarily be judged by her parents.
For the purposes of illustration, let us consider two possible courses of action. On the one hand, mechanical ventilation can be withdrawn to allow Kandice to die. On the other hand, it can be maintained on a long-term basis. In the former case, Kandice could benefit from the prevention of long-term daily suffering that can result from her significant physical disability, rendering her dependant on technology to sustain her respiration, and on complete care for all of her physical needs such as feeding, elimination, bathing, and
ambulation. However, she would also suffer the “burden” of losing her life, consequently deprived of pleasures that she may be capable of experiencing.
Otherwise, ventilation could be maintained “permanently”. She would benefit from a prolonged life, with all of the possibilities it could offer (e.g., receive her family‟s love,
parental authority and children‟s rights in this setting were closely debated and articulated (i.e., late 1960s to the Baby Doe case in 1982); (2) following the Baby Doe case, significant initiatives were undertaken to attempt to develop national standards for treatment decisions regarding newborns; and (3) consistent decision-making criteria and policies were established. In The Lazarus case, Lantos (2001) presents a fictitious medical malpractice case in neonatology, drawn from his own medical experience, to examine fundamental ethical concerns in neonatal intensive care such as: standards of care, prognostication, futility, consent, decision-making, and medical errors. Heimer and Staffen (1998) conducted an ethnographic examination of the social organization of responsibility in two American neonatal intensive care units. They highlighted that the responsibilities of parents and HCP toward critically ill newborns are socially produced and sustained, rather than prescribed by ethical and legal norms. For a brief historical overview of medical ethics in neonatology, see Placencia & McCullough (2011). For additional discussions of the challenges involved in assessing a child‟s best interests in relation to parents‟ interests, see: Cornfield & Kahn (2012) and Lantos (2006).
5 nurturance, and comfort). But, this prolonged life would also be arguably severely limited, entailing significant daily suffering and deprivation.
These two treatment options, withdrawal or maintaining mechanical ventilation, involve a comparative weighing of value-laden phenomena or “goods”; e.g., the inherent value of life as a worthwhile good in itself “versus” the potential for “quality” fulfillment of that life (i.e., sanctity of life versus quality of life).
In the modern West, there exists no agreed upon hierarchy of values to resolve how these goods ought to be weighed in Kandice‟s case. It is therefore commonly recognized that parents should assess the course of treatment that would serve the child‟s best interests, in light of the family views they wish to cultivate for their family; with the exception of actions that might be regarded as neglectful or abusive toward the child. Parents are required to, and have a right to, “freely” choose whether it is best for Kandice to be ventilated or not.
Questioning the Dominant Ethical Framework in Pediatric Medicine
Despite the development of these norms, why do cases such as Kandice emerge as ethical dilemmas? Is the problem simply a technical legal issue of determining which questions are medical and which are parental? Do they merely involve questions regarding the interpretation of these norms, which at times will require an analysis by the agent designated by society with the ultimate interpretational authority: a court?
In this thesis I argue that cases such as Kandice are inadequately understood and reconciled with the dominant ethical framework in pediatric medicine and bioethics.7 Such
7 For the purposes of this thesis, “bioethics” refers the prevalent mode of inquiry that has emerged in modern
6
cases frequently demonstrate that “best interests determination procedures” result in significant moral residue; involved agents commonly face persisting moral dilemmas or distress.8,9 This results from dominant procedures that narrowly construe that which is morally meaningful and disregard additional realms of moral life as morally less significant. For example, in a case involving life-sustaining treatments for a child,
determining the child‟s best interests unfolds in a context where agents are also striving to be “a good parent” or a “good doctor, nurse, or hospital”, among others. A child‟s interests dwell within a broader moral landscape of additional interests such as family interests, parental interests, sibling interests, clinician interests, institutional and state interests, among others.10 Moreover, the moral lives of these agents can involve dimensions
specifically critiquing a division of bioethics that attends to medical problems, which has adopted a primarily
principlist framework - particularly in North America (Beauchamp & Childress, 2001). Principlism is
examined and critiqued more thoroughly in subsequent chapters of this thesis.
8 For a detailed discussion of “moral distress” in relation to the care of critically ill children, see: Austin,
Kelecevic, Goble, & Mekechuk, 2009. In Carnevale (2007), I relate the sense of moral residue that is
frequently encountered in pediatric critical care to the tragic choices commonly encountered by clinicians and families; referring to tragedy as depicted in ancient Greek literature. That is, incontrovertible dilemmas where even virtuous agents are drawn into choices and actions that feel morally bad.
9 Footnote #6 in this introduction outlines selected literature on contemporary ethical issues in pediatrics,
highlighting that pediatric medicine involves a wide range of ethical problems, which are commonly inadequately reconciled with current ethical frameworks. This helps justify the need for the investigation conducted in this thesis.
10 A critical examination of the best interests standard in pediatrics is published in a 1997 theme issue of the
Journal of Medicine and Philosophy (Volume 22 Issue 3), edited by Loretta Kopelman. In the opening
commentary, Kopelman (1997a) discusses how the best interests standard affects moral and ethical decisions for children; reviewing the uses as well as the criticisms of the best interests standard. Downie & Randall (1997) discuss the rights of parents to decide on behalf of infants and young children in terms of the
importance of preserving intimate family relationships, rather than in terms of the child's best interests, while highlighting legal, ethical, and financial constraints on parental decision making. Clayton (1997) examines the allocation of decision-making authority between parents and physicians for genetic testing in children. De Ville (1997) reviews the problem of who should serve as surrogate decision makers for the children of adolescent parents, calling for a greater level of watchfulness over the competency and decisions of
adolescents making decisions for their children, but not definitive enough to conclude that, as a group, they be presumed incapable of making those decisions. Kopelman (1997b) examines a wide range of issues relating to the best interests standard. She highlights prominent criticisms of this standard as self-defeating,
individualistic, unknowable, vague, dangerous, and open to abuse. Despite these concerns, Kopelman defends this standard by identifying its employment as (a) a threshold for intervention and judgment (e.g., child abuse and neglect rulings); (b) an ideal to establish policies or prima facie duties; and, (c) a standard of
7 extending beyond their mere “interests”, including for example, rights and obligations as well as socio-culturally transmitted mores.
The dominant ethical framework in pediatric medicine and bioethics is inherently problematic because important moral considerations are concealed, congruent with the common displacement of moral malaises in modernity articulated by Charles Taylor.11
I argue in this thesis – in line with Taylor – that contemporary pediatric medicine and bioethics are reflective of modern moral theory, which is centered on decisional procedures without explicit regard for the substantive moral grounds that such procedures should relate to. Ethical questions refer (implicitly or explicitly) to some ultimate goods that are commonly concealed and unarticulated in modernity. Modern medicine and corresponding ethical frameworks mistakenly rely on a narrow conception of moral life.
Taylor has critiqued modern moral theory for its implicit endorsement of modern naturalism wherein notions of the “good” are relegated to matters of contemporary values. That is, moral sentiments are regarded as subjective human reactions to a presumed neutral objective physical world. This characterizes moral phenomena as “non-real.”
Taylor has highlighted that modern Western societies have privileged (a)
individualism, (b) instrumental reason, and (c) political atomism as primary goods (Taylor, 1991). This is traced to fundamental features of modern scientific and social revolutions that have assigned a primordial significance to the affirmation of ordinary life and the manipulation of the physical world to serve the ends of humanity.
11 I acknowledge the numerous debates regarding the definitions attributed to “moral” and “ethical” – which I
did not intend to advance in this investigation. For the purposes of clarity of articulation, I use the term “moral” to refer to background or underlying conceptions of the good, right, or just, while “ethical” refers to practice conceptions of the good, right, or just. For example, the former can relate to societal or community values or beliefs, while the latter can refer to conduct or normative statements regarding conduct (e.g., codes of ethics, practice standards).
8
The goal of this thesis is to examine moral concerns in contemporary pediatric medicine through Taylor‟s hermeneutical framework and his investigations of modernity. That is, Taylor‟s work orients this examination (a) methodologically, as his conception of hermeneutics serves as the analytical framework for the thesis, and (b) substantively, drawing on his analysis of modernity and moral theory to inform this investigation of pediatric medicine.
This investigation relates to a broader body of literature that has critiqued the “dominant ethical paradigm” within medicine and bioethics in general, and pediatric medicine and pediatric bioethics in particular.12 Indeed, some writers have already argued that hermeneutics can make important contributions to bioethics.13 However, these papers have limited their focus to the development of novel approaches to clinical ethical
12 Some of these critiques are reviewed in chapter 5.
13 For examples, see: Carson (1990; 2011); Daniel (1986); Svenaeus (1999; 2003); Thomasma (1994); and
Betan (1997). Carson (1990) criticizes the common approach to bioethics as tethered to a social contract view of the doctor-patient relationship that is largely incompatible with experiences of illness and care and as a formalist doctrine that lacks critical edge and tends toward “accommodationism”. He argues for a
hermeneutical alternative that interprets moral experience by means once associated with the rhetorical arts: practical reasoning, hermeneutics, casuistry, and thick description. In a later work, Carson (2011) discusses Taylor's retrieval of an expressivist understanding of persons and of language as constitutive of meaning as important insights for restoring moral connectedness between patients and physicians. Daniel (1986) proposes a hermeneutical model as an orientation to clinical decision-making, considering a patient is analogous to a literary text that can be interpreted on four levels: (1) the literal facts of the patient's body and the literal story told by the patient, (2) the diagnostic meaning of the literal data, (3) the praxis emanating from the diagnosis, and (4) the change effected by the clinical encounter in both the patient's and clinician's life-worlds. Svenaeus (1999) calls for a shift away from a view of medicine as an assembly of applied scientific theories and technologies to a view of medicine as a practice of healing with a central structure that is the meeting between the physician and patient – this meeting is construed as a clinical hermeneutics. Drawing on the hermeneutic philosophy of Gadamer, Svenaeus argues how the physician and patient strive to reach a common
interpretation of the clinical problem. Svenaeus (2003) also considers medical practice as an interpretative meeting between physician and patient, wherein the good physician comes to know what to do for a particular patient at a particular time through hermeneutical interpretation. Thomasma (1994) regards clinical ethics and medical decision-making as a unitary hermeneutics, arguing that clinical ethics interprets the clinical situation in light of a balance of values that guide the decision-making process while also contributing to the very weighting of those values. The clinical case originates ideas about which value ought to predominate as well as the origin of interpretive rules that can be used in other cases. Betan (1997) articulates a hermeneutic model for psychotherapists that recognizes the context of the therapeutic relationship and the therapist's subjective responses as fundamental considerations in the interpretation and application of ethical interventions.
9 problems.14 They have not advanced hermeneutics as a framework for a philosophical (rather than clinical) examination of moral concerns in contemporary medicine in general, and in pediatrics in specific.
Thus, this thesis makes original contributions in articulating (a) a hermeneutical philosophical methodology for examining moral problems in medicine as well as (b) a philosophical analysis of the moral malaises of modern pediatric medicine.
It should be highlighted that this investigation is not a critique of Taylor‟s
philosophy. Many significant examinations of Taylor‟s work have already been conducted; many of which are cited in this thesis.15 Rather, this investigation builds on some of
14 Gadamer‟s The Enigma of Health (1996) is a notable exception. In this collection of essays, Gadamer
challenges the dominant conception of medicine as disproportionately centered on science and technical mastery. He argues for a greater recognition of the “artful” dimension of medical practice, which involves hermeneutical interpretation and judgement.
15 For example: Abbey, 2004a; Benner, 1994a; Carnevale & Weinstock, 2011; Gagnon, 2002; Laforest & de
Lara, 1998; Pélabay, 2001; Redhead, 2002; Smith, 2002; Tully, 1994. Published examinations of Taylor‟s work provide further discussions and critiques of his ideas. The selected examples cited in this thesis refer primarily to book form publications, because they offer more substantive examinations. There exist, however, a very large number of additional papers and journal theme issues, as well as additional books. The
“investigations of Taylor” cited in the thesis are selected primarily for illustrative purposes. The cited works should not be considered exhaustive, as it is not the primary aim of this thesis to present a comprehensive critique of Taylor‟s ideas. Some commentators on Taylor‟s work have focused primarily on “disseminating” his large body of work, bringing together specific or general aspects of his work in a single integrated whole, offering selected syntheses and interpretations. For example, Abbey (2000) presents an introduction to Taylor‟s ideas, focusing primarily on his work on moral theory, selfhood, political theory, and epistemology. Abbey draws out ideas that overarch Taylor‟s writings while also addressing some of the published critiques of Taylor‟s work. Smith (2002) has published an exemplary overview of Taylor‟s “philosophical
anthropology”, reviewing his work on the human sciences, personal identity, language, moral life,
multiculturalism, and secularization. Smith presents a critical synthesis of Taylor‟s ideas in these domains. Some work has articulated Taylor‟s work in other languages (e.g., French) to promote the circulation of Taylor‟s ideas among additional scholars and readerships. For example, Gagnon (2002) has published a highly comprehensive French-language overview of Taylor‟s work, structured in terms of Taylor‟s
philosophical and moral orientation, as well as well as his work on ethics and democracy. Pélabay (2001) has prepared a French-language discussion of selected arguments in Taylor‟s political philosophy. She examines Taylor‟s politics of recognition, in relation to his work on freedom and tradition, equality and difference, individualism and community, with a particularly extensive examination of Taylor‟s notion of deep diversity. A number of published works offer further insight, interpretation, and critique of Taylor‟s work. For example, Redhead (2002) has published a critical discussion of aspects of Taylor‟s political philosophical analysis of Quebec and Canada. Redhead highlights what he considers problems in Taylor‟s notions of deep diversity and
political fragmentation, while also examining other aspects of Taylor‟s philosophy such as self-interpretation,
and catholic modernity. Redhead offers re-articulations that he argues could help resolve these problems. Mulhall (2004) has outlined the intellectual links between Taylor‟s moral theory and political theory; particularly examining atomism, negative freedom, and politics of recognition. The collection edited by
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Taylor‟s most highly supported examinations of hermeneutics and modernity in pushing his work further by adapting it for a philosophical analysis of modern pediatric medicine (i.e., in chapters 3 to 5) and to propose a re-conception of the practice of pediatric bioethics (i.e., in chapter 6); while also advancing Taylor‟s own work by attempting to articulate an operationalization of his hermeneutical “methodology” (i.e., in chapter 2).
Why the Philosophy of Charles Taylor?
Why was the philosophy of Charles Taylor selected to orient the analysis
undertaken in this thesis? This choice was based on several factors. As described above, persistent moral concerns in pediatric medicine have been described, for which the dominant framework in pediatric bioethics appeared inadequate. This ongoing problem sparked my search for an alternative moral and ethical orientation.
I had my earliest encounter with Taylor‟s work in the 1980s, through the research of Patricia Benner. Benner is an internationally acclaimed nursing researcher at the University of California in San Francisco who has articulated a qualitative research methodology for the health sciences, drawing heavily on Taylor‟s hermeneutical philosophy (Benner, 1994a).16 This motivated me to read Taylor‟s work directly – stimulating my interest in Laforest and de Lara (2001) reviews a number of Taylor‟s philosophical arguments in relation to “intellectual traditions of the French language”. This includes examinations of Taylor‟s hermeneutics, political theory, epistemology and philosophical anthropology, including a contribution by Taylor himself. Philosophy in an
age of pluralism: The philosophy of Charles Taylor in question, a collection edited by Tully (1994), presents
a strongly comprehensive critical review of Taylor‟s work, followed by Taylor‟s direct replies to his “critics” (Taylor, 1994a). This book also lists an extensive bibliography of Taylor‟s earlier published books and papers (Tully, 1994, 258-264). Orlie (2004) discusses how Taylor‟s philosophy relates to feminist discourse. This relation has been scarcely reviewed; indeed, Taylor‟s own references to feminist thought have been limited. Orlie argues that Taylor‟s work can help advance feminist inquiry. Abbey (2004b) has highlighted that some ideas within Taylor‟s work would appear to readily intersect with feminist thought, such as embodied knowing, as well as the critique of the reification of science and atomistic individualism. Additional critical discussions of Taylor‟s work are cited throughout the thesis in relation to particular fields of inquiry.
16 Benner subsequently published a leading articulation of hermeneutical approaches to empirical research;
11 both his philosophical orientation in general and his analysis of modernity in specific. My reaction to this early reading is best characterized by a quote by Jeremy Webber (University of Victoria legal scholar), while he was speaking at a 2012 conference in Montreal to celebrate Taylor‟s eightieth birthday, “After I first read Taylor‟s Interpretation and the Sciences of Man, the whole world looked different to me”.17 This was the same for me. I had a series of “aha” moments in reading Taylor‟s conception of the human sciences, critique of contemporary moral theory, and the malaises of modernity. Richer ways of understanding pediatric medicine were illuminated, as I had worked clinically in pediatrics since the mid-1970s as a pediatric critical care nurse. I saw opportunities for novel
understandings – yet very little work had related Taylor‟s ideas to clinical problems to date. I was further motivated by the clearly significant importance of Taylor‟s work in
contemporary philosophy; his work was highly acclaimed through awards and a growing number of books devoted to his philosophy. Moreover, Taylor‟s presence in Quebec, providing opportunities for direct discussion with him, consolidated the decision to work with his ideas.
As this project was taking shape, it became readily apparent that there were a number of additional problems in contemporary medicine that could benefit from Taylorian investigations, yet were beyond the scope of this thesis.18 I therefore spearheaded, in
17 Several Quebec university departments and various partners organized a conference in Montreal to
celebrate Taylor‟s 80th birthday, inviting twenty-seven paper presentations to discuss a wide range of Taylor‟s work; followed by Taylor‟s commentaries on each paper. The conference took place on March 29-31, 2012. The conference program is posted online [http://www.creum.umontreal.ca/IMG/pdf_prog_final.pdf] along with audio recordings of the proceedings [http://www.creum.umontreal.ca/taylor/].
18 Taylor himself has scarcely addressed modern medicine in his writings, with two noteworthy exceptions:
(a) a discussion of cultural and acultural conceptions of modernity that describes modernity as a movement from one constellation of background understandings to another that repositions the self in relation to others and the good (see: Two Theories of Modernity, Taylor, 1995a) and (b) a political philosophical examination of “caring” in medicine in which he reviews the impact of procedural liberalism – the ways in which caring is undermined by bureaucratic rule (see: Philosophical Reflections on Caring Practices, Taylor, 1994b).
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collaboration with philosopher Daniel Weinstock, a parallel project to publish - in the Journal of Medicine and Philosophy - a collection of papers examining epistemological, ontological, moral, and political philosophy problems in medicine, in light of Taylor‟s philosophy (Carnevale & Weinstock, 2011).19
Plan for the Thesis
In chapter 1, I outline Taylor‟s hermeneutical philosophy. This requires a discussion of the shifts in philosophical orientations in the human sciences that preceded Taylor‟s work, to set the “intellectual landscape” within which Taylor‟s ideas emerged. Taylor has argued that a hermeneutic framework cannot be understood merely as a set of analytical techniques. I discuss Taylor‟s moral framework and hermeneutical “method” as a particular line of thought emerging out of the hermeneutical human sciences. Moreover, Taylor‟s examination of modernity is discussed in detail, including his review of the “malaises of modernity”. Taylor‟s work in this domain provides a substantive moral groundwork against which contemporary phenomena – such as modern pediatric medicine – can be analyzed. In line with Taylor‟s socio-historical hermeneutical philosophy, pediatric medicine cannot be examined in a vacuum. It is important to trace the horizons of significance and social imaginaries against which pediatrics emerged and became aligned with particular moral orientations. Taylor situates the moral life of agents in modernity within a contemporary horizon where the ultimate grounding of the moral life has been concealed by espousing presumably neutral ethical decisional models. He has advanced a philosophical outlook that
19 This theme issue of the Journal of Medicine and Philosophy (Carnevale & Weinstock, 2011) includes an
introductory paper by myself and Daniel Weinstock that provides an overview of Taylor‟s ideas, followed by papers by Hubert Dreyfus, Patricia Benner, Gilles Bibeau, Carl Elliott, Natalie Stoljar, Ronald Carson, Dawson Schultz and Lydia Flasher, Laurence Kirmayer, and Daniel Weinstock. The final piece is an
interview discussion with Taylor that examines several issues raised in the theme issue (Taylor, Carnevale, & Weinstock, 2011).
13 resists dominant “proceduralist” models, continually seeking to understand the moral
horizon and social imaginary within which moral concerns are situated.
Chapter 1 draws primarily on Taylor‟s works more directly aligned with the focus of this thesis, including his examinations of epistemology and ontology in the human sciences, moral philosophy, and modernity. Much of his political philosophical work was not regarded as directly applicable,20 with the exception of portions of his analysis of multiculturalism. Taylor‟s “rapprochement” is adapted in my formulation of a practice framework for pediatric bioethics in chapter 6. A Secular Age (2007), Taylor‟s most recent “opus magnum” is not explicitly related into the analysis for this thesis, because it was published at a time when the “Taylorian” framework for the thesis was largely developed and some of the preliminary examinations of pediatric medicine were already underway. The significant amount of time required to gain a strong grasp of this voluminous work did not seem necessary, given that some of Taylor‟s earlier examinations of secularization were already accessible through his earlier analyses of modernity, which have been incorporated into this thesis.
In chapter 2, I outline an operational explicitation of Taylor‟s hermeneutical approach to articulate the “Taylorian methodology” used in this thesis. This
operationalization of Taylor‟s hermeneutical philosophy is another innovative contribution of this thesis.
Chapter 3 presents an analysis of the early history of pediatric medicine. This starts with a sketch of the early social construction of childhood, leading to the medicalization of infant mortality and childhood health and development, with the “birth” of pediatric
20 Taylor has also published important examinations of the philosophy of Georg Wilhelm Friedrich Hegel.
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medicine. This was initially grounded on a utilitarian-oriented moral foundation, where the well-being of infants and children became valued as a support for state and societal
economic and military activity. In the middle of the 1900s, a more child-centered moral orientation emerged, anchored on the best interests standard.
In chapter 4, I articulate a detailed examination of the best interests standard; documenting its early emergence in law, followed by its adaptation into pediatric medicine. Three notable issues relating to moral concerns in pediatric medicine are highlighted and discussed in terms of the challenges that they imply.
These three issues are further examined in chapter 5 as three principal moral malaises in modern pediatric medicine: (a) the convergence of law and ethics; (b) the construal of children as incapable and dependent; and (c) the ambiguous nature of best interests. These malaises are examined to the retrieve the background horizons of significance and social imaginaries against which they were shaped.
In chapter 6, I present a Taylorian framework for the practice of pediatric bioethics: a framework for hermeneutical retrieval and rapprochement. This framework is designed to enrich pediatric practice through interpretive attunement and reconciliation of commonly concealed moral considerations.
In the conclusion, I present a synthesis of the contributions developed in the thesis, along with an outline of implications for future research as well as pediatric practice and education.
15 Chapter 1: Hermeneutics and the Philosophy of Charles Taylor
Introduction
In this chapter, I discuss Taylor‟s “methodological” contribution to the
philosophical analysis of moral problems: hermeneutics – the methodological framework used for this thesis. Hermeneutics cannot be understood simply as a set of techniques. Hermeneutics is rooted in an underlying ontology and epistemology – a philosophical re-conception of the nature of phenomena and how they can be understood.
Given the significant scope of this chapter, it is divided into three major sections. In the first section, I outline shifting perspectives in the human sciences and the corresponding emergence of hermeneutical inquiry in philosophy, to situate Taylor‟s orientation
historically and intellectually.
In the second section, I review Taylor‟s moral framework and hermeneutical
approach as a particular line of thought emerging out of the hermeneutical human sciences. Taylor‟s moral framework provides several important concepts that help orient the analysis of pediatric medicine conducted in this thesis.
In the third section, substantive aspects of Taylor‟s hermeneutical analyses of modernity are reviewed. Specifically, Taylor‟s examination of moral malaises as well as shifting conceptions of the self are discussed. This discussion helps illuminate the social context within which modern pediatric medicine emerged, while also illustrating Taylor‟s hermeneutical methodology through demonstration.
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Section I
Shifting Perspectives in the Human Sciences
Understanding Taylor‟s hermeneutical framework requires an examination of the intellectual landscape within which it emerged. The following discussion of the historical emergence of hermeneutics outlines how this can be traced to fundamental shifts in the human sciences. This tracing of the “sources” of hermeneutics informs the subsequent discussion of specific ideas articulated by Taylor. Moreover, this examination of hermeneutics in light of its corresponding historical context is consistent with Taylor‟s historically-centered conception of hermeneutics.
It should be noted that hermeneutical inquiry is a vast field of scholarship. The “genealogy” traced here is restricted to the most significant influences on the emergence of Taylor‟s philosophical orientation.1 Moreover, some portions of the review in this section are very brief, in the interests of succinctness and because it is not a goal for the thesis to undertake an analysis of the historical foundations of hermeneutics. This review is intended primarily to orient the subsequent discussion of the “emergence” of Taylor‟s ideas. There is no intention to discount the importance of the many hermeneutical works that have been excluded.
1
For a more detailed review, see Thouard (2011). Thouard‟s edited collection of papers reviews
hermeneutical examinations of various foundational themes such as understanding, interpretation, human sciences, analysis of texts, and hermeneutical knowledge. The collection includes a translated version of Taylor‟s Interpretation and the sciences of man, an excerpt from Gadamer‟s Truth and Method, along with contributions from Dilthey, Simmel, and Engel, among others.
17 Since its emergence in the seventeenth century, the word hermeneutics has referred to the science or art of interpretation (Grondin, 1991/1994, p. 1).
Contemporary hermeneutics is most strongly related to the work of Schleiermacher, Dilthey, Heidegger, and Gadamer.2 Although, philosophical examinations of interpretation have existed since antiquity in some form or another (e.g,, Aristotle‟s De Interpretatione), Grondin points out that in the ordinary sense, philosophical hermeneutics “refers to the philosophical position of Hans-Georg Gadamer” (Grondin, 1991/1994, p. 2). Gadamer is recognized as a most influential thinker in the development of philosophical hermeneutics, and will thus figure prominently in sections of this chapter.3
The human sciences faced a methodological challenge in post 19th century thought because they had come to see themselves as analogous to the natural sciences. In the English tradition, Mill regarded the human sciences as seeking regularities and conformities to law that would make it possible to predict individual phenomena and processes. For Gadamer, the human sciences do not seek to understand individual cases as instances of a universal rule. Rather, a phenomenon should be understood as a unique thing in itself – how a person or persons happened to become what they are.4
2 Ricoeur also developed a hermeneutical framework, which differed from that of Gadamer (example:
Ricoeur, 1991). This discussion of historical context will focus primarily (but not exclusively) on Gadamer as his hermeneutics established a highly dominant position with which Taylor‟s hermeneutics is highly aligned, without any intention of diminishing the importance of Ricoeur‟s outlook. Ricoeur has directly intersected with some of Taylor‟s work. Some of this work is cited later in this chapter in the discussion of Taylor‟s
Sources of the Self.
3 In addition to articulating his own hermeneutical framework, Gadamer‟s Truth and Method (1960/1994) also
presents one of the most recognized historical accounts of the “evolution” of hermeneutic philosophy in the human sciences, which strongly informs the discussion presented in this section.
4 Although hermeneutical orientations to the human sciences emerged in contrast to outlooks that were more
closely aligned with the natural sciences, many schools of thought in the human sciences have followed the latter to the present day. Indeed, a diversity of theoretical orientations are employed in this domain. Some scholars, such as Lincoln & Guba (2000) have argued that there exists a diversity of “paradigms” in the human sciences, drawing on Kuhn‟s (1970) important concept for distinguishing intellectual outlooks. That is, some orientations appeal to fundamentally distinct ontological presuppositions about the human sciences and how these can be understood epistemologically and methodologically. These distinctions are commonly expressed in terms of polemic oppositions relating to: objectivism/subjectivism, explanation/understanding, positivistic appeal to observables/interpretation, individualism/holism, among others. Two prominent poles
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Although he distinguished the human sciences from the natural sciences, Dilthey was significantly influenced by the latter, embracing the “spirit” of the natural sciences and “objective” scientific distancing from the phenomenon of interest (Dilthey 1991; 1996; 2002). This inferior characterization of the human sciences was rejected by “German classicism” as it contested Enlightenment rationalism. Rather, humanism was embraced in the 19th century, centered on the concepts of self-formation, education, and cultivation (i.e., Bildung). The early meaning of Bildung related to the external form of a thing that was regarded as “natural”. This has now come to signify the idea of culture – in particular, the developing of one‟s natural capacities.
The human sciences orientation appealed to the sensus communis – a special kind of “common sense”, resembling the practical wisdom of phronesis described by Aristotle. This involves a capacity to grasp a situation in a manner that cannot be prescribed by the rational concept of knowledge. This does not refer to “the abstract universality of reason
have emerged: on the one hand, a positivistically rooted explanatory objectivism that draws on ontological and epistemological frameworks from the natural sciences, while on the other hand a hermeneutically-oriented interpretive subjectivism that is centered on understanding. Proponents of the first “paradigm” argue that the human sciences can and should subscribe to the scientific models of the natural sciences, given the extraordinary successes of the latter, favoring an epistemology that draws on measurement, quantification, the formulation of exact laws, and the verification of explanatory hypotheses through experimental methods. These proponents include Bunge (1998; 1999), Harris (1979), Thurstone (1928), Tolman (1932), and Watson (1919), among others. The second “paradigm” assumes that phenomena in the human sciences are shaped by the human agents that identify these phenomena, incontrovertibly relying on interpretations that are in turn shaped by the particular “thought styles” employed (to borrow a term from Hacking, 1985). These proponents include Gaines (1992), Geertz (1973), Kleinman (1988), Packer & Addison (1989), and Rosaldo (1993), among others. For the purposes of illustration, I have characterized this ongoing debate polemically; however, I acknowledge that many outlooks that have developed within the human sciences do not fit neatly within either “extreme” of this polemic or may draw on aspects of either pole. Moreover, some diverse outlooks have emerged even within the “extreme” poles. The two paradigms described above should not be considered homogenous. For example, Hollis (1994) has attempted to demonstrate that these debates can be further “complexified” by contrasting objectivism/subjectivism and individualism/holism through an orthogonal four-quadrant constellation of these outlooks. This gives rise to four (not two) discernable paradigms for the social sciences: objectivist-individualist, objectivist-holist, subjectivist-individualist, and subjectivist-holist. Berthelot (2001) has tried to address these epistemological/ontological polemic divides by proposing a third intermediate view - a nonreductionistic rationalism that strives to identify constitutive and functional rules for social phenomena. Valade (2001) and Ogien (2001) have published thorough examinations of the problem of holism and individualism in the human sciences.
19 but the concrete universality represented by the community of a group, a people, a nation, or the whole human race” (Gadamer, 1960/1994, p.21). This emphasizes the “common” in common sense – highlighting its social dimension. Sensus communis also implies an ethical dimension – grasping with a moral control that distinguishes what should be done from what should not be done. There is something compelling about grounding the human sciences on the concept of sensus communis, rather than theoretical reasoning, which cannot govern the human passions nor adequately advance our understanding of humanity. However, this tradition of thinking has been displaced in contemporary times by the methodological thinking of modern science.
This perspective in the human sciences, shifting toward a hermeneutic conception of Bildung and sensus communis, set the stage for an epistemological transition to
hermeneutics.
Understanding, Interpretation and Hermeneutical Philosophy
The hermeneutical approach to understanding and interpretation initially developed along two different outlooks: (1) theological hermeneutics which was oriented toward the interpretation of biblical texts; and (2) philological hermeneutics oriented toward classical literature and the understanding of linguistic practices. In both cases, hermeneutics
involved an attempt to uncover concealed meanings from the texts in question.
Luther‟s theological hermeneutics (aiming to direct the Reformation understanding of the Bible toward individual persons) emphasized the significance of the context of the text to be understood – the text could not be understood in isolation. This corresponds with some approaches to linguistic analysis, whereby a word or a sentence could not be
20
understood without consideration of the broader text (paragraph, page, chapter, etc.). Similarly, historical analysis should rely on such contextual review.
The initial development of interpretation as a methodology is attributed to
Schleiermacher. Although he was a theologian and never actually published a philosophical account of his hermeneutical framework, his work advanced hermeneutics by
demonstration. Schleiermacher challenged the philological approach to interpretation, which he considered as wrongfully centered on techniques. Rather, he attempted to search beyond the texts themselves, focusing his interpretation on the understanding of thoughts. For Schleiermacher, understanding involved a coming together and arriving at a shared understanding – an agreement – regarding the subject matter. He defined hermeneutics as the art of avoiding misunderstandings, bringing to light the truth embedded within a text.
Schleiermacher complemented the grammatical sense of interpretation with psychological interpretation, which was taken up further by other interpretivists, namely Dilthey. Psychological interpretation involves putting yourself within the way of thinking of the author. Although such thinking is highly individual, it can be understood because of a pre-existing bond among all persons – a manifestation of universal life. Interpretation should lead to an understanding of which the writer may have been largely unconscious.
Dilthey is credited for his elaboration of a historical hermeneutics (Dilthey, 1991; 1996; 2002).5 He developed a logical analysis of history wherein detail could only be understood in terms of the whole and the whole could only be understood in terms of its detail – an orientation drawn from romantic hermeneutics. Contrary to Hegelian idealism, Dilthey asserted that ideas are only imperfectly represented in history. Therefore
philosophy needs to be replaced by historical research in order to enlighten man‟s
21 understanding of himself and where he stands within the world. Historical analysis
uncovers a continuity such that the historically real can emerge according to the laws of succession, where events are understood in terms of what has preceded. Historical
coherence is formed by an unconscious teleology that excludes the insignificant from this coherence.
Dilthey sought to create a new epistemology – being concerned about how the historical school positioned itself between the idealism philosophy of Kant and Hegel and that of experience, where the “pure science of reason” was extended to the historical sciences. For Dilthey, experience in the human sciences is quite different from experience in the natural sciences. The historical world is not based on facts taken from experience but rather our inquiry must draw on an inner historicity belonging to experience itself.
Experience is a “living historical process” that fuses memory and expectation into a whole. The historical world to be understood is always constructed by the human mind.
Experience is to be the ultimate ground for understanding the historical world – experience understood as an indivisible whole of act (of becoming conscious) and content (that of which one is conscious).
Dilthey‟s epistemology shifts the focus from the coherence of an individual‟s experience to historical coherence that is beyond individual consciousness. This involves a shift from a psychological to a hermeneutical foundation for the human sciences. However, this raises an important problem. How can a historical coherence (that no individual is conscious of) be understood? First, this involves a move away from the causal explanation employed in the natural sciences to an epistemology of understanding and expression.
Phenomenological investigation reveals that what emerges is not the outcome of causal forces but rather an intelligible whole – a structural continuity – that can be
22
understood in itself regardless of any system of cause and effect. Dilthey referred to this whole as significance.
Dilthey examined the problem of how infinite historical understanding can be possible for a finite human nature or mind. Through the use of comparative methods, it is possible to rise above individual experience and apprehend “universal truths.”6
For Dilthey, knowledge exists in life itself, wherein it is unreflectively connected with experience. A reflective analysis requires a shifting out of one‟s own goals – striving for a comprehension of stability through contemplation and practical reflection. Dilthey saw a commonality between the natural and human sciences, both seeking to rise methodologically above the realm of individual subjective understanding. He guarded against relativity by striving toward totality.
Husserl argued that, for phenomenological inquiry, prior modes of understanding should be bracketed. Experience is examined collectively as a form of transcendental reflection. Every experience has implicit horizons of before and after, fusing with the continuum of the experiences present in the before and after to form a unified flow of experience.
Husserl implicitly relied on the notion of horizon to account for how systems of meaning merge into a continuity of the whole (1931/1960; 1936/1970). In contrast to the concept of world conventionally understood within the natural sciences, Husserl developed the concept of life-world. Here, persons are seen as immersed in a transient world – in a constant movement of relative validity wherein the world is anchored in a communal subjectivity.
6 Gadamer (1960/1994) subsequently criticized Dilthey on this view, for this comparison presupposes that the
knowing subject has the capacity to understand both things contemporaneously. How can consciousness rise above its own relativity? Consciousness is always immersed in a particular historical context.
